Eclampsia

Audience Emergency medicine residents. Introduction Eclampsia is the development of a generalized seizure in pregnant patients with hypertension of pregnancy.1 Eclampsia exists on the spectrum of hypertension-related disorders in pregnancy, occurs in 1 out of 1,000–10,000 deliveries,1–3and is associated with significant maternal and fetal morbidity and mortality.4 Given the emergent nature of eclampsia and the benefit of rapid treatment, emergency medicine (EM) physicians need to quickly recognize and treat this rare pathology. Although residents have three to four years before becoming an attending, not all emergent pathologies may present clinically during their training. It is important to simulate rare, treatable conditions such as eclampsia to give learners exposure confidence in managing this disease. Educational Objectives By the end of this simulation session, learners will be able to: Demonstrate care of a gravid patient with altered mental status Demonstrate care of a gravid patient with seizures Recognize care involved in assessment of fetal status Execute appropriate subspecialty consultation Recognize the clinical signs and symptoms of eclampsia Distinguish different treatment options for eclampsia Identify magnesium toxicity and reversal agent Differentiate the spectrum of preeclampsia Educational Methods As an educational strategy, simulation allows learners to partake in experiential learning. By creating a safe and supportive learning environment, simulation allows learners to facilitate deliberate practice and transfer learning in debriefing sessions. High-fidelity sessions involve software and technology to mimic realistic patient environments, which also activate learners’ affective states to aid in decision-making abilities in complex medical cases. This session was conducted using a high-fidelity mannequin, SimMom (Laerdal), and a controlling Laerdal LLEAP Software. Faculty-led debriefing followed the simulation case and included discussion regarding presentation, spectrum, and management of the obstetrical emergency.5 Research Methods Resident participants completed an evaluation form consisting of questions on a 5-point Likert scale assessing the realism and usefulness of the simulation. Results All 18 residents who participated in the simulation completed an evaluation form, and all agreed or strongly agreed the case was realistic and useful. Discussion Incorporating high-stakes, low-frequency presentations through simulation can be readily applied in residency education and well-received by residents. Increasing the difficulty through adjusting the clinical history and exam may challenge learners further. Topics Medical simulation, eclampsia, pregnancy, obstetrics, emergency medicine.

This simulation was taught to 18 EM residents in a four-year residency program. Prior to beginning the simulation, learners were oriented to the simulation center and high-fidelity mannequins. Learners were divided into groups by residency leadership to distribute skill levels across teams. Given limited decision-makers in this case, we recommend groups of three. Of note, we assigned groups of four or five given the presence of medical student rotators and limited time availability of simulation equipment. The operator of the mannequin can be anyone with a script to the case but should have basic knowledge of how to communicate through the mannequin and change digital vital signs. Finally, an EM faculty member observer was present in the room to evaluate the team as well as troubleshoot any unexpected issues. The faculty member had a list of predetermined critical actions on which to evaluate the team and a debriefing guide that outlined the objectives of the case.

List of Resources:
Abstract

Objectives:
By the end of this simulation session, the learner will be able to: 1. Demonstrate care of a gravid patient with altered mental status 2. Demonstrate care of a gravid patient with seizures 3. Recognize care involved in assessment of fetal At the end of the debriefing, residents completed an evaluation form for the case. 18 out of 18 (100%) residents completed an evaluation. Six PGY-1, five PGY-2, two PGY-3, and five PGY-4s completed the surveys. Surveys were anonymous, and the University Institutional Research Board approved this study. All participants agreed (n =13) or strongly agreed (n=5) the simulation was realistic and useful. Selected comments are below: Positive: • "Seems very bread and butter, known problem, known solution and a good review of the standard medications" (PGY 1) • "I liked the monitoring for med toxicity/effects" (PGY 2) • "A rare case is always helpful to do especially without OB present" (PGY 3) • "Was realistic and nice to review what we do not see every day" (PGY 4) Some suggested comments for improvement include "having a family to talk to," "access to ultrasound images," and "making IV access difficult." Of note, the structure of the university ED has a separate OB triage managed by the OBGYN department; pregnancy-related complaints above 15 weeks are not often seen in the university ED. This likely influenced resident positive reception of the case and comments related to not seeing such pathology. If senior residents desire increased difficulty, this case could be modified using a postpartum patient or a past medical history of diabetes or epilepsy to present alternative treatment considerations for seizures. Background and brief information: EMS bring a 24-year-old female to a tertiary medical center confused after what appeared to be a seizure.

Initial presentation:
The patient arrives by EMS without family. She is an appropriately dressed female who has altered mental status.
How the scene unfolds: On arrival, learners should assess the patient's airway, breathing, and circulation while obtaining any additional information from EMS before they leave. They should attempt to perform a history and focused physical exam on the patient who will be unable to provide any additional information because of altered mental status. They should recognize the patient is gravid, and obtain IV access while performing a finger-stick blood glucose which will be normal. They should notify obstetrics and gynecologists who will be unavailable for a short period and recommend the learner provide treatment. Learners should perform fetal heart monitoring while giving anti-hypertensive medications and magnesium sulfate. As the patient is monitored in the ED, the patient exhibits symptoms of magnesium toxicity and will require reversal with calcium. The case ends with disposition to the OR with OB. • History of present illness: o Paramedic history: Fire rescue states they were called to the scene for a witnessed seizure at home. Per family, the patient had some facial twitching, and then the patient's whole body was shaking, and she was unresponsive for about 2 minutes. She was incontinent of urine at the scene. She has no prior history of seizures or any other medical problems. No known trauma. o Patient history: Patient unable to provide history secondary to altered mental status initially only stating "my head hurts." However, as the case progresses with correct actions the patient will become more awake and will complain of a mild headache, blurring of vision, right upper quadrant pain, and bilateral lower extremity swelling. o If asked: The patient is 31weeks pregnant by dates and has only had 1 prenatal appointment in the first trimester but nothing since then.

Eclampsia: Definition, Pathophysiology
Eclampsia is one of the obstetrics emergency clinicians should be familiar with because it carries one of the highest mortality and morbidity rates for both the mother and the baby. 10 It causes a mortality rate of 14% worldwide. 4 According to the American Board of Emergency Medicine Model of Practice, pre-eclampsia and eclampsia are included as one of the critical pathologies emergency physicians should be able to manage. 11 Thus, it is essential for Emergency Medicine residents to be familiar with the recognition and the management of eclampsia.
Eclampsia is defined as "the occurrence of one or more generalized tonic-clonic convulsions unrelated to other medical conditions in women with hypertensive disorder of pregnancy." 1 Although it is not precisely known, there are a few hypotheses why this disorder occurs. One of the theories involves the change in autoregulation in the central nervous system and the brain-blood barrier. Another theory involves the overregulation of the central nervous system and its result of vasoconstriction. 12

Eclampsia: Presentation, "It is a spectrum."
Emergency providers have difficulty recognizing this obstetrical emergency because of its atypical presentation and its wide spectrum of preeclampsia to eclampsia. Preeclampsia can also be divided further into a mild form and a severe form based on severe features and abnormal lab parameters.
Chronic hypertension is the elevated blood pressure of at least 140/90 on 2 separate occasions at least 4 hours apart diagnosed before 20 weeks of gestation, while gestational hypertension is defined as high blood pressure after 20 weeks of gestations without proteinuria and without any features or preeclampsia. This is also important because about half of patients with gestational hypertension may develop preeclampsia or eclampsia. 13 The mild form of preeclampsia is defined as gestational hypertension plus either of the following: • Evidence of proteinuria defined as>300mg/24hour urine specimen (including 2 dipstick readings>2+ taken 6 hours apart), or protein to creatinine ratio >0. 3 The severe form differs from the mild form with a higher blood pressure parameter and severe features. First, the blood pressure should be greater than or equal to the systolic blood pressure of 160 mmHg or the diastolic blood pressure of 110mmHg or higher on two separate occasions at least 4 hours apart on bed rest. 13 Some severe feature findings include a) pulmonary edema or hypoxia, b) renal insufficiency, serum creatinine >1.1 mg/dL or doubling creatinine in the absence of kidney disease, c) new-onset headache, d) presence of visual disturbances, e) persistent epigastric or right upper quadrant pain, f) impaired liver function tests, g) generalized weakness, h) bleeding at intravenous insertions, i) thrombocytopenia <100,000 and j) altered mental state. 14 Eclampsia differs from preeclampsia because it is the convulsive presentation of hypertensive obstetrical emergency. 13 Seizures can manifest with tonic-clonic, focal or multifocal seizures without a history of seizures.
Despite the differences in definition, preeclampsia and eclampsia can present any time between 20 weeks of gestation to 4 weeks postpartum. These hypertensive emergencies should be recognized and managed promptly since 1 in 400 women with preeclampsia with mild features and 1 in 50 women with preeclampsia with severe features develop eclampsia, which remains a significant cause of maternal death worldwide. 13 A prompt recognition and management of this obstetrical emergency is paramount to decrease the morbidity and mortality associated with the condition.

Pre-Eclampsia & Eclampsia: Management Part 1: Seizure Prophylaxis and Seizure treatment
In an emergency, physicians should resuscitate with airway, breathing, and circulation before further management or investigation of the patient.
The management of seizure can be divided into two-folds: prophylaxis and treatment. The seizure prophylaxis is indicated in patients with preeclampsia with severe features. Since these patients' likelihood of developing into eclampsia is high, the American College of Obstetrics and Gynecology recommends magnesium load. 13 It is important to be familiar with the dosing of magnesium. Magnesium is loaded with 4-to-6 grams 10% magnesium sulfate in 100ml solution via IV over 15 minutes. Then, a continuous infusion of 1-2 grams/hour should follow. Studies have not demonstrated any mortality or morbidity benefit in patients with preeclampsia with mild features. 1

DEBRIEFING AND EVALUATION PEARLS
Once the patient is actively seizing in the scenario, it is crucial to clear the secretions and prevent asphyxiation and aspiration. After that, seizure should be aborted as soon as possible.
Learners should realize that the first line of seizure treatment in eclampsia is not anticonvulsants but rather magnesium. The dosing is the same as the seizure prevention. If seizures recur in real-life settings, physicians can give an additional dose of 2g bolus of magnesium sulfate. 1 However, physicians should start to think of alternative diagnoses and administer anticonvulsants, lorazepam, or phenytoin, if seizures are refractory to eclampsia's corrective measures.
The dosing of magnesium is significantly higher than what is typically used to treat other pathology. This may lead to some confusion for nurses where they may not feel comfortable administering the medication. Thus, it is essential to communicate the indication, the reason, and side effects to monitor for the medication. Symptoms of hypermagnesemia can be rapid and start to manifest around the level of 3.5. Symptoms observed include nausea and somnolence (level 3-4), the loss of deep tendon reflex and muscle weakness (level 4-8), respiratory failure (level 8-12), hypotension, bradycardia and cardiac collapse (level 12-15). EKG changes (prolonged PR, increased duration of QRS complex, prolonged QTc, increased amplitude of T waves and delayed conduction) vary and do not correlate with the level of magnesium. If patients have a normal patellar reflex, respiratory rate >12, and urine output >100cc, the magnesium maintenance therapy can be continued. 15 If any side effects occur, physicians should stop the medication and give the antidote, calcium gluconate 10% 1.5-3g, via IV. Also, since the medication is cleared via kidneys, the medication dose should be adjusted in renal failure patients-furthermore, some relative contraindications of the medication in myasthenia gravis, pulmonary edema, and renal edema. 16 Besides the prophylaxis and chemical treatment, learners should also emergently consult the obstetrics team for definitive eclampsia management: delivery. However, learners need to understand that the patient should be resuscitated and free of seizure before transport to the delivery room.

Pre-Eclampsia & Eclampsia: Management Part 2: Calling Consultants
Obstetricians should be called emergently with patients who present with both preeclampsia and eclampsia. This is to evaluate the fetus for fetal heart rate and monitoring and assess the need for an emergent delivery because it is the most definitive treatment of preeclampsia and eclampsia. Especially to patients who present with preeclampsia with severe features after 34 weeks of gestation, there are delivery criteria that obstetricians will look for: non-reassuring fetal heart activity, uncontrollable blood pressure, oliguria, markedly elevated creatinine, pulmonary edema, hypoxia, development of HELLP (hemolysis, elevated liver enzymes, low platelets), right upper quadrant tenderness, or any pregnancy complications such as ruptured membranes, oligohydramnios, intrauterine growth restriction. Most of the time, emergency providers will not have any supporting documents, such as lab values, because it takes time for returns. However, informing obstetricians of a potential obstetrics emergency based on other collaterals such as vital signs or symptoms can alert them to evaluate the patient and the fetus emergently. 7 When calling consultants, learners need to be concise and direct. There is the "5C's" model, which stands for: contact, communicate, core question, collaborate, and close the loop. This model was extensively studied in medical students but had the most extensive evidence of making a high-quality consult. 17 Besides, learners should include pertinent information specific to each specialty. For example, in this simulated case, learners should include gravida/para status, gestational week, presenting issue, ultrasound/lab results (if present), and the last oral intake, since there might be a need for the patient to go to the operating room.

Pre-Eclampsia & Eclampsia Management Part 3: Blood Pressure Management
Since the definition of preeclampsia and eclampsia entails hypertension, learners should not only recognize but also correctly measure blood pressure. The blood pressure should be taken in either a sitting or semi-reclining position on the right arm with the right size cuff. Once learners realize that it is true hypertension, then there should be a few safe and effective antihypertensive agents that should come to mind to utilize in pregnant patients. Several medications can be used to lower the blood pressure effectively: hydralazine, labetalol, nifedipine, nicardipine, nitroglycerine, or nitroprusside. Although effective, providers should be cautious of the side effects medications can manifest. Labetalol is cautioned against patients with low heart rates because it blocks the atrioventricular node of the heart.

Critical Actions:
Place IV, obtain vitals and a finger-stick glucose Perform primary survey (airway, breathing, circulation) Obtain a basic history of symptoms Perform physical exam and recognize pregnancy Verbalize "eclampsia" and call obstetrics consult early Emergent blood pressure management (labetalol or hydralazine) Treat seizure with magnesium Recognize magnesium toxicity Provide antidote for magnesium toxicity Clearly communicate with consultants and nurses with the management goals and disposition Summative and formative comments: